Provider Demographics
NPI:1356932677
Name:LUCAS, ROBERTA ANN (MA PSYCHOLOGY, LLP)
Entity type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:ANN
Last Name:LUCAS
Suffix:
Gender:F
Credentials:MA PSYCHOLOGY, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-3144
Mailing Address - Country:US
Mailing Address - Phone:313-359-3161
Mailing Address - Fax:
Practice Address - Street 1:23810 MICHIGAN AVE STE 202B
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1830
Practice Address - Country:US
Practice Address - Phone:313-359-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361006317103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical